A case of racemose and intraventricular neurocysticercosis in an unusual location

Racemose and intraventricular neurocysticercosis are uncommon types of neurocysticercosis, resulting in a multiloculated, grape-like cluster appearance in the cerebrospinal fluid (CSF) spaces. A male patient presented with symptoms of raised intracranial pressure and demonstrated racemose neurocysticercosis at an atypical location involving the region of the crus of the fornix at the level of the body of lateral ventricles on magnetic resonance imaging. Associated intraventricular neurocysticercosis was seen in the atrium of the left lateral ventricle and fourth ventricle.

Asymptomatic idiopathic intracranial hypertension post female to male gender transition

A 23- year-man post female to male (FTM) gender transition was found to have bilateral papilloedema at a routine optician visit. The patient was referred on for formal ophthalmological and neurological assessments. Optical coherence tomography (OCT) confirmed the presence of bilateral papilloedema. The patient was entirely asymptomatic and had no medical history. He took testosterone intramuscularly once per month. Neurological examination was otherwise normal. Investigations including routine blood panels, CT brain, MRI brain and cerebral MR venogram were all normal. Lumbar puncture yielded cerebrospinal fluid (CSF) normal in appearance but demonstrated raised intracranial pressure. In the absence of other causative aetiologies a diagnosis of idiopathic intracranial hypertension (IIH) was made. Treatment was commenced with acetazolamide and the patient was discharged with outpatient ophthalmological and neurological follow-up.

Evolving Evidence in Idiopathic Intracranial Hypertension

Idiopathic intracranial hypertension (IIH) is an enigmatic disorder characterized by raised intracranial pressure (ICP) with no known cause and it affects both children and adults [...]

Mannitol is comparable to hypertonic saline for raised intracranial pressure in Acute Liver Failure (MAHAL Study): A RCT

Background: Raised intracranial pressure due to cerebral edema (CE) is central to development of hepatic encephalopathy in ALF. Mannitol (MT) & Hypertonic saline (HS) has been shown to improve CE. We compared the efficacy & safety of the two modalities Methods: ALF with CE were prospectively randomized in an open study to receive either 5 ml/kg of either 3% HS, as continuous infusion; titrated every 6 hourly to achieve serum sodium of <160(Group A; n=26) or 1 g/kg of 20% MN as a IV bolus, repeated every six hourly (Group B; n=25) in addition to standard ALF care. Primary end-point was reduction of intracranial pressure defined as optic nerve sheath diameter <5mm and middle cerebral arterial pulsatility index (PI) <1.2 at 12 hours. Results: Fifty-one patients with ALF, hepatitis E being commonest (33.3%), median jaundice to HE interval of 8(1-16) days, were randomized to HS (n=26) or MN (n=25). Baseline characteristics were comparable including King’s college criteria [>2: 38.4% vs.40%]. Overall, 61.5% patients in HS and 56% in MN group showed reduction in ICP at 12 hr. (p=0.25). Rebound increase in ICP indices was noted in 5(20%) patients in MT and none in HS (p<0.05) group. New onset acute kidney injury was commoner in MT than HS group. The ICU stay, and 28-day transplant free survival were not different between the groups. Conclusions: While both agents had comparable efficacy in reducing ICP and mortality in ALF patients was comparable, HS was significantly better in preventing reducing rebound CE with lower renal dysfunction.

Left Frontal Lobe Tumor-Induced Intraoperative Premature Ventricular Beats

In the absence of cardiac pathology, premature ventricular contractions (PVCs) in neurosurgical patients frequently accompany subarachnoid hemorrhage, intracerebral hemorrhage, traumatic brain injury, or raised intracranial pressure. PVCs detected during preanesthesia assessment prompts detailed cardiac evaluation. Our 57-year-old patient, a case of left frontal meningioma, with controlled hypertension, diabetes and hypothyroidism, had normal preoperative ECG and potassium. However, immediately on anesthesia induction, she developed multiple refractory to treatment PVCs but with normal blood pressure. Anesthesia, which was maintained with sevoflurane and fentanyl, was deepened to exclude light anesthesia as the cause, without useful outcome. Two lignocaine boluses (100 mg each), followed by its infusion, also proved ineffective. Her blood gases and potassium, checked twice, were normal. Throughout, her hemodynamics remained stable. As soon as tumor was removed, the PVCs disappeared not to return. Her postoperative recovery was uneventful with normal ECG.

Complete hemispheric exposure vs. superior sagittal sinus sparing craniectomy: incidence of shear-bleeding and shunt-dependency

Purpose Decompressive hemicraniectomy (DC) has been established as a standard therapeutical procedure for raised intracranial pressure. However, the size of the DC remains unspecified. The aim of this study was to analyze size related complications following DC. Methods Between 2013 and 2019, 306 patients underwent DC for elevated intracranial pressure at author´s institution. Anteroposterior and craniocaudal DC size was measured according to the postoperative CT scans. Patients were divided into two groups with (1) exposed superior sagittal sinus (SE) and (2) without superior sagittal sinus exposure (SC). DC related complications e.g. shear-bleeding at the margins of craniectomy and secondary hydrocephalus were evaluated and compared. Results Craniectomy size according to anteroposterior diameter and surface was larger in the SE group; 14.1 ± 1 cm vs. 13.7 ± 1.2 cm, p = 0.003, resp. 222.5 ± 40 cm2 vs. 182.7 ± 36.9 cm2, p < 0.0001. The SE group had significantly lower rates of shear-bleeding: 20/176 patients; (11%), compared to patients of the SC group; 36/130 patients (27%), p = 0.0003, OR 2.9, 95% CI 1.6–5.5. There was no significant difference in the incidence of shunt-dependent hydrocephalus; 19/130 patients (14.6%) vs. 24/176 patients (13.6%), p = 0.9. Conclusions Complete hemispheric exposure in terms of DC with SE was associated with significantly lower levels of iatrogenic shear-bleedings compared to a SC-surgical regime. Although we did not find significant outcome difference, our findings suggest aggressive craniectomy regimes including SE to constitute the surgical treatment strategy of choice for malignant intracranial pressure.

Neurology

Impaired consciousness, Headache, Raised intracranial pressure, Acute bacterial meningitis, Epidemic meningococcal disease, Viral meningitis, Chronic meningitis, Encephalitis, Rabies, Tetanus, Stroke, Subarachnoid haemorrhage, Subdural haemorrhage, Extradural haematoma, Blackouts/syncope, Space-occupying lesions (SOL), Brain abscess, Hydrocephalus, Epilepsy, Status epilepticus, Cysticercosis, Weak legs and spinal cord disease, Guillain-Barré syndrome, Poliomyelitis (polio), Peripheral neuropathy, Leprosy, Dementia